The relationship between frailty and polypharmacy in older people: A systematic review

Identification and prediction of frailty among community-dwelling older Japanese adults based on Bayesian network analysis: a cross-sectional and longitudinal study

BACKGROUND

Frailty is a multifactorial syndrome; through this study, we aimed to investigate the physiological, psychological, and social factors associated with frailty and frailty worsening in community-dwelling older adults.

METHODS

We conducted a cross-sectional and longitudinal study using data from the "Community Empowerment and Well-Being and Healthy Long-term Care: Evidence from a Cohort Study (CEC)," which focuses on community dwellers aged 65 and above in Japan. The sample of the cross-sectional study was drawn from a CEC study conducted in 2014 with a total of 673 participants. After excluding those who were frail during the baseline assessment (2014) and at the 3-year follow-up (2017), the study included 373 participants. Frailty assessment was extracted from the Kihon Checklist, while social relationships were assessed using the Social Interaction Index (ISI). Variable selection was performed using Least Absolute Shrinkage and Selection Operator (LASSO) regression and their predictive abilities were tested. Factors associated with frailty status and worsening were identified through the Maximum-min Hillclimb algorithm applied to Bayesian networks (BNs).

RESULTS

At baseline, 14.1% (95 out of 673) participants were frail, and 24.1% (90 out of 373) participants experienced frailty worsening at the 3-years follow up. LASSO regression identified key variables for frailty. For frailty identification (cross-sectional), the LASSO model's AUC was 0.943 (95%CI 0.913-0.974), indicating good discrimination, with Hosmer-Lemeshow (H-L) test p = 0.395. For frailty worsening (longitudinal), the LASSO model's AUC was 0.722 (95%CI 0.656-0.788), indicating moderate discrimination, with H-L test p = 0.26. The BNs found that age, multimorbidity, function status, and social relationships were parent nodes directly related to frailty. It revealed an 85% probability of frailty in individuals aged 75 or older with physical dysfunction, polypharmacy, and low ISI scores; however, if their social relationships and polypharmacy status improve, the probability reduces to 50.0%. In the longitudinal-level frailty worsening model, a 75% probability of frailty worsening in individuals aged 75 or older with declined physical function and ISI scores was noted; however, if physical function and ISI improve, the probability decreases to 25.0%.

CONCLUSION

Frailty and its progression are prevalent among community-dwelling older adults and are influenced by various factors, including age, physical function, and social relationships. BNs facilitate the identification of interrelationships among these variables, quantify the influence of key factors. However, further research is required to validate the proposed model.

Potentially inappropriate anticholinergic drug use among older adults in primary healthcare: prevalence and determinants

BACKGROUND

Considering the vulnerability of older adults to adverse drug reactions, medications with strong anticholinergic properties are considered potentially inappropriate for this population. This study aims to characterize older adults' profile of anticholinergics use and to identify the factors associated with their potentially inappropriate use.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted on 1200 older adults in primary health care centers of Portugal between April 2021 and August 2022. Potentially inappropriate use was assessed according to the 2023 Beers criteria. Logistic regression analyses were performed to determine associations between independent variables and potentially inappropriate use.

RESULTS

A 8.9% (95% CI 0.074-0.107) of the older adults were exposed to one or more potentially inappropriate anticholinergics, and amitriptyline was the most used (2.0%). Multivariate analysis revealed that use was associated with a higher mean number of medications (OR 1.173, 95% CI 1.115-1.234), diagnoses of depression (OR 2.889, 95% CI 1.785-4.674) and psychiatric disorders (OR 1.654, 95% CI 1.003-2.729).

CONCLUSIONS

This study underscores the importance of vigilance in prescribing anticholinergic medications to older adults, particularly those with higher medication burdens and mental health diagnoses. By identifying factors associated with potentially inappropriate use, healthcare providers can better tailor medication regimens to mitigate risks and optimize the well-being of older adults.

Economic cost-benefit analysis of person-centred medicines reviews by general practice pharmacists

BACKGROUND

Medicines reviews by general practice pharmacists improve patient outcomes, but little is known about the associated economic outcomes, particularly in patients at higher risk of medicines-related harm.

AIM

To conduct an economic cost-benefit analysis of pharmacists providing person-centred medicines reviews to patients with hyperpolypharmacy (prescribed ≥ 10 regular medicines) and/or at high risk of medicines-related harm across multiple general practice settings.

METHOD

Service delivery costs were calculated based on the pharmacist's salary, recorded timings, and a general practitioner fee. Direct cost savings were calculated from the cost change of patients' medicines post review, projected over 1 year. Indirect savings were calculated using two models, a population-based model for avoidance of hospital admissions due to adverse drug reactions and an intervention-based model applying a probability of adverse drug reaction avoidance. Sensitivity analyses were performed using varying workday scenarios.

RESULTS

Based on 1471 patients (88.4% with hyperpolypharmacy), the cost of service delivery was €153 per review. Using the population-based model, net cost savings ranging from €198 to €288 per patient review and from €73,317 to €177,696 per annum per pharmacist were calculated. Using the intervention-based model, net cost savings of €651-€741 per review, with corresponding annual savings of €240,870-€457,197 per annum per pharmacist, were calculated. Savings ratios ranged from 181 to 584% across all models and inputs.

CONCLUSION

Person-centred medicines reviews by general practice pharmacists for patients at high risk of medicines-related harm result in substantial cost savings. Wider investment in general practice pharmacists will be beneficial to minimise both patient harm and healthcare system expenditure.

Exploring the correlates of frailty among hospitalized older adults: A cross-sectional study in a Saudi teaching hospital

Frailty is an important public health concern associated with aging. It increases the risk of adverse clinical outcomes, such as falls, late-life dependency, hospitalization, disability, and mortality. The objectives of this study were to estimate the prevalence of frailty and to identify factors associated with frailty among older adults (≥65 years) admitted to King Abdulaziz University Hospital, Jeddah, Saudi Arabia. This cross-sectional study was conducted at King Abdulaziz University Hospital. The data were collected during the months of January and February 2022 and included demographic characteristics, comorbidities, length of stay, and hospital mortality. Frailty status of participants was assessed using the Clinical Frailty Scale. A total of 147 patients (aged ≥ 65 years) were included in our study. The prevalence rates of frailty and non-frailty were 71.4% and 28.6%, respectively. Frail patients had higher comorbidity index (P = .003), polypharmacy (P = .003), heart failure (P = .001), and prolonged hospital stays (P = .007). The results of the multiple logistic regression revealed that the tall patients had a lower risk of frailty (odds ratio = 0.0089, 95% confidence interval: 0.0001-0.7588, P = .042) and patients with higher comorbidity indexes had higher risk of frailty (odds ratio = 1.4907, 95% confidence interval: 1.1449-1.9927, P = .004). In this study, more than two-thirds of the hospitalized older patients were classified as frail. High comorbidity index, heart failure, and polypharmacy were strong predictors of frailty. Patients with frailty were more likely to have a prolonged hospital stay than those without frailty. Therefore, early detection of frailty and proper intervention are essential for improving health outcomes in this vulnerable population.

Polypharmacy Management in Chronic Conditions: A Systematic Literature Review of Italian Interventions

Background: Potentially inappropriate polypharmacy (PIP) is among the major factors leading to adverse drug reactions, increased healthcare costs, reduced medication adherence, and worsened patient conditions. This study aims to identify existing interventions implemented to monitor and manage polypharmacy in the Italian setting. Methods: A systematic literature review (PROSPERO: CRD42023457049) was carried out according to the PRISMA statement guidelines. PubMed, Embase, ProQuest, and Web of Science were queried without temporal constraints, encompassing all published papers until October 2023. Inclusion criteria followed the PICO model: patients with polypharmacy; interventions to monitor/manage polypharmacy regimen versus no/any intervention; outcomes in terms of intervention effectiveness and cost variation. Results: After duplicate deletion, 153 potentially relevant publications were extracted. Following abstract and full-text screenings, nine articles met the inclusion criteria. Overall, 78% (n = 7) were observational studies, 11% (n = 1) were experimental studies, and 11% (n = 1) were two-phase studies. A total of 44% (n = 4) of the studies involved patients aged ≥ 65 years, while 56% (n = 5) were disease-specific. Monitoring was the most prevalent choice of intervention (67%; n = 6). Outcomes were mainly related to levels of polypharmacy (29%; n = 6) and comorbidities (29%; n = 6), effectiveness rates (14%; n = 3), and avoidable costs (9%; n = 2). Conclusions: This review outlines that Italy is still lacking in interventions to monitor/manage PIP, addressing an unmet need in developing patient-tailored strategies for reducing health-system burden.

Effects from medications on functional biomarkers of aging in three longitudinal studies of aging in Sweden

Antihypertensive, lipid-lowering, and blood glucose-lowering drugs have slowed down the aging process in animal models. In humans, studies are limited, have short follow-up times, and show mixed results. Therefore, this study aimed to estimate the effects of commonly used medications on functional aging, cognitive function, and frailty. We included information on individuals from three Swedish longitudinal population-based studies collected between 1986 and 2014. Our exposures were the 21 most used groups of medications among individuals aged 65 years and older in the Swedish population in 2022. Functional aging index (n = 1191), cognitive function (n = 1094), and frailty index (n = 1361) were the outcomes of interest. To estimate the medication effects, we used a self-controlled analysis, where each individual is his/her own control, thereby adjusting for all time-stable confounders. The analysis was additionally adjusted for time-varying confounders (chronological age, Charlson Comorbidity Index, smoking, body mass index, and the number of drugs). The participants were 65.5-82.8 years at the first in-person assessment. Adrenergics/inhalants (effect size = 0.089) and lipid-modifying agents/plain (effect size = 0.082) were associated with higher values of cognitive function (improvement), and selective calcium channel blockers with mainly vascular effects (effect size = -0.129) were associated with lower values of the functional aging index (improvement). No beneficial effects were found on the frailty index. Adrenergics/inhalants, lipid-modifying agents/plain, and selective calcium channel blockers with mainly vascular effects may benefit functional biomarkers of aging. More research is needed to investigate their clinical value in preventing adverse aging outcomes.

Harmonizing the definition of medication reviews for their collaborative implementation and documentation in electronic patient records: A Delphi consensus study

BACKGROUND

Medication review practices have evolved internationally in a direction in which not only physicians but also other healthcare professionals conduct medication reviews according to agreed practices. Collaborative practices have increasingly highlighted the need for electronic joint platforms where information on medication regimens and their implementation can be documented, kept updated, and shared.

OBJECTIVE

The aim of this study was to harmonize the definition of medication reviews and create a unified conceptual basis for their collaborative implementation and documentation in electronic patient records (definition appellation: collaborative medication review).

METHODS

The study was conducted using the Delphi consensus survey with three interprofessional expert panel rounds in September-December 2020. The consensus rate was set at 80%. Experts assessed the proposed definition of collaborative medication review based on an international and national inventory of medication review definitions. The expert panel (n = 41) involved 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals. The range of response rates for the rounds was 63-88%.

RESULTS

The experts commented on which of the pre-selected items (n = 75) characterizing medication reviews should be included in the definition of collaborative medication review. The items were divided into the following five themes and 51 of them reached consensus: 1) Actions included in the collaborative medication review (n = 24/24), 2) Settings where the review should be conducted (n = 5/5), 3) Situations where the review should be considered as needed and carried out (n = 10/11), 4) Prioritization of top five benefits to be achieved by the review and 5) Prioritization of top five patient groups to whom the review should be targeted.

CONCLUSIONS

A strong interprofessional consensus was reached on the definition of collaborative medication review. The most challenging was to identify individual patient groups benefiting from the review.

Probing polypharmacy, ageing and sex effects on physical function using different tests

BACKGROUND

Ageing, sex and polypharmacy affect physical function.

OBJECTIVES

This mouse study investigates how ageing, sex and polypharmacy interact and affect grip strength, balance beam and wire hang, correlating and comparing the different test results between and within subgroups.

METHODS

Young (2.5 months) and old (21.5 months) C57BL/6 J male and female mice (n = 10-6/group) were assessed for physical function at baseline on grip strength, balance beam and wire hang with three trials of 60 s (WH60s) and one trial of 300 s (WH300s). Mice were randomised to control or diet containing a high Drug Burden Index (DBI, total anticholinergic and sedative drug exposure) polypharmacy regimen (metoprolol, simvastatin, citalopram, oxycodone and oxybutynin at therapeutic oral doses). Following 6-8 weeks of treatment, mice were reassessed.

RESULTS

High DBI polypharmacy and control mice both showed age group differences on all tests (p < 0.05). Only control mice showed sex differences, with females outperforming males on the WH60s and balance beam for old mice, WH300s for young mice (p < 0.05). Polypharmacy reduced grip strength in all subgroups (p < 0.05) and only in old females reduced wire hang time and cumulative behaviour and balance beam time and %walked (p < 0.05). Physical function assessments were all correlated with each other, with differences between subgroups (p < 0.05), and mice within subgroups showed interindividual variability in performance.

CONCLUSION

Age, sex and polypharmacy have variable effects on different tests, and behavioural measures are useful adjuvants to assessing performance. There was considerable within-group variability in change in measures over time. These findings can inform design and sample size of future studies.

Frailty and Parkinson's disease: the role of diabetes mellitus

Parkinson's disease (PD) is a chronic neurodegenerative disease associated with a progressive loss of dopaminergic neurons, clinically characterized by motor and non-motor signs. Frailty is a clinical condition of increased vulnerability and negative health outcomes due to the loss of multiple physiological reserves. Chronic hyperglycemia and insulin resistance, which characterize diabetes mellitus (DM), have been reported to alter dopaminergic activity, increase the risk of PD, and influence the development of frailty. Even though diabetes may facilitate the development of frailty in patients with PD, this relationship is not established and a revision of the current knowledge is necessary. Furthermore, the synergy between DM, PD, and frailty may drive clinical complexity, worse outcomes, and under-representation of these populations in the research. In this review, we aimed to discuss the role of diabetes in the development of frailty among patients with PD. We summarized the clinical characteristics and outcomes of patients with concomitant DM, PD, and frailty. Finally, interventions to prevent frailty in this population are discussed.

Association between Physical Function, Mental Function and Frailty in Community-Dwelling Older Adults: A Cross-Sectional Study

Background: This study examines the relationship between physical and mental function and frailty, independently and in conjunction with polypharmacy, among older adults. Methods: This cross-sectional study consisted of 368 participants aged ≥60 years. The participants were categorized into either robust or frail groups using Fried's frailty phenotype. Physical functions were assessed using grip strength, gait speed, Timed Up and Go (TUG), the Five Chair Sit to Stand Test (FCSST) and the Six-Minute Walk Test (SMWT). Mental functions were assessed using cognitive function and depression. Cognitive function was measured using Mini-Mental State Examination (MMSE). Depression was assessed with the Korean version of the Short Geriatric Depression Scale (SGDS). Results: The mean age of study population was 75.4 years. In this population, we identified 78.8% (n = 290) robust participants and 21.2% (n = 78) frail participants. The study examined frailty status (frail vs. non-frail) and frailty with and without polypharmacy using multivariate logistic regressions, adjusting for age and sex. In the logistic regression model estimating the risk of frailty, after adjustments for age, sex, BMI, and number of medications, individuals with low SMWT showed a significantly increased risk of frailty, with an odds ratio (OR) of 8.66 and a 95% confidence interval (CI) of 4.55-16.48. Additionally, global cognitive function was associated with a 1.97-fold increase in frailty risk (95% CI: 1.02-3.67). Moreover, in models adjusted for age, sex, and BMI to assess frailty risk linked to polypharmacy, the TUG, SMWT, and SGDS all showed increased risks, with ORs of 3.65 (95% CI: 1.07-12.47), 5.06 (95% CI: 1.40-18.32), and 5.71 (95% CI: 1.79-18.18), respectively. Conclusions: Physical function (SMWT, FCSST, TUG) and mental function (depression, cognition) were associated with frailty. By comprehensively examining these factors, we will gain valuable insights into frailty and enable more precise strategies for intervention and prevention.

Effects of Exercise on Frailty in Older People Based on ACSM Recommendations: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives: The objective of the study was to carry out an analysis of the methodological quality of clinical trials (effects of exercise on frailty in older people) based on ACSM recommendations. Methods: The search scope included PubMed, Embase, Web of Science, Cochrane, and literature that cannot be retrieved from the database. The topic was the impact of exercise on frailty in elderly people. Changes in five outcome measures (FP, BI, SPPB, GS, and BMI) were assessed using mean differences (MD) and 95% confidence intervals (95% CI). A random effects model (RE) was used to conduct a meta-analysis and compare the results between subgroups. Results: The intervention effects of exercise on the five outcome indicators of frailty in elderly people were all significant (p < 0.05). The effect of a high-consistency subgroup on outcome indicators FP and GS was more significant than that of the low- or uncertain-consistency subgroup (MD: -1.09 < -0.11, MD: 2.39 >1.1). There was no significant difference in the intervention effect as reflected in the outcome measures SPPB and BMI in the high-consistency subgroup (p = 0.07, p = 0.34). There was no significant difference in the impact of the intervention on the outcome measure BI between the two subgroups (p = 0.06, p = 0.14). Conclusions: Exercise prescriptions with high consistency with ACSM recommendations may be more effective in both FP and GS interventions than those with uncertain or low consistency. However, it is essential to note that the data derived from the meta-analysis is still subject to the small number of studies, the unknown degree of consistency of participants in individual studies, and the different mix of cases in the studies.

The Influencing Factors of Frailty and Quality of Life in Elderly Patients After Spinal Surgery

Background

To study the related factors of frailty and quality of life in elderly patients after spinal surgery.

Methods

The anxiety, depression, frailty, and quality of life of all patients were assessed by the Anxiety screening scale (GAD-7), Depression screening scale (PHQ-9), Frailty screening scale (FRAIL), and European five-dimensional health scale (EQ-5D-5L) 1 day before surgery (DAY-0). A numeric rating scale (NRS) was used to evaluate patients' pain during activities on the 1st day (POD-1), 3rd day (POD-3), and 30th day (POD-30) after operation. FRAIL scale and EQ-5D-5L were used to evaluate patients' frailty and quality of life on POD-30 and 90th day (POD-90) after the operation.

Results

There were significant differences in age, body mass index (BMI), preoperative serum albumin level (ALB), and NRS score on POD-1 between the two groups (P<0.05). Age and PHQ-9 score were positively correlated with EQ-5D-5L score (P<0.05, r Age=0.245, rPHQ-9=0.217), and preoperative ALB level was negatively correlated with EQ-5D-5L score (P<0.05, r ALB=-0.274).

Conclusion

The older the age, the larger the BMI and the higher the NRS score on the first day after surgery, the more prone to frailty in elderly patients after spinal surgery; The older age and the lower the preoperative ALB level, the worse the quality of life in elderly patients after spinal surgery.

Definition, assessment and management of frailty for people with intellectual disabilities: A scoping review

BACKGROUND

People with intellectual disabilities may experience frailty earlier than the general population. This scoping review aimed to investigate how frailty is defined, assessed, and managed in adults with an intellectual disability; factors associated with frailty; and the potential impact of COVID-19 on frailty identification and management.

METHOD

Databases were searched from January 2016 to July 2023 for studies that investigated frailty in individuals with intellectual disabilities.

RESULTS

Twenty studies met the inclusion criteria. Frailty prevalence varied between 9% and 84%. Greater severity of intellectual disability, presence of Down syndrome, older age, polypharmacy, and group home living were associated with frailty. Multiagency working, trusted relationships and provision of evidence-based information may all be beneficial in frailty management.

CONCLUSION

Frailty is common for people with intellectual disabilities and is best identified with measures specifically designed for this population. Future research should evaluate interventions to manage frailty and improve lives.

Frailty and Health-Related Quality of Life in Elderly Patients Undergoing Esophageal Cancer Surgery: A Longitudinal Study

PURPOSE

This study aims to elucidate the longitudinal alterations in frailty and health-related quality of life experienced by elderly patients undergoing surgical treatment for esophageal cancer. Additionally, it seeks to ascertain the impact of preoperative frailty on postoperative health-related quality of life over time.

METHODS

131 patients were included in the prospective study. Patients' frailty and health-related quality-of-life were assessed utilizing the Tilburg and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 at preoperative, 1 week, 1 month, and 3 months, postoperatively. Statistical analyses were performed using generalized estimating equations, repeated-measures analysis of variance, and linear mixed models (LMMs).

RESULTS

Out of 131 patients, 28.2% had frailty before surgery, and the prevalence of frailty consistently higher after surgery compared with baseline (67.9%, 51.9%, and 39.7%). There was no significant change in frailty scores in preoperative frail patients within 3 months following surgery (p = .496, p < .999, p < .999); whereas in preoperative non-frail patients, the frailty scores increased at 1 week (p < .001) and then decreased at 1 month (p = .014), followed by no change at 3 months. In addition, preoperative frail patients had significantly worse global quality-of-life (β = -4.24 (-8.31; -.18), p = .041), physical functioning (β = -9.87 (-14.59; -5.16), p < .001), role functioning (β = -10.04 (-15.76; -4.33), p = .001), and social functioning (β = -8.58 (-15.49; -1.68), p = .015), compared with non-frail patients.

CONCLUSIONS

A significant proportion of participants exhibited a high prevalence of preoperative frailty. These patients, who were preoperatively frail, exhibited a marked reduction in health-related quality-of-life, a more gradual recovery across various functional domains, and an increased symptom burden during the follow-up period. Therefore, it is crucial to meticulously identify and closely monitor patients with preoperative frailty for any changes in their postoperative physiology, role, and social functioning.

Pilot Testing of Useful Tools' Validity for Frailty Assessment in Greece: Translated PRISMA-7 Tool, Modified Fried Criteria and Clinical Frailty Scale

The importance of frailty in older people is getting constant recognition as an important aspect both in terms of public health, as well as at a personal level, for the appropriate management of an older person's health condition. This is reflected by the continuously increasing number of research studies carried out in several settings across different countries. Sometimes, this is very solid, but in other cases, there is a considerable gap in terms of accurate and well-grounded documentation of frailty status. This is the case in Greece, where we are missing clinically validated tools to approach frailty. We are missing frailty screening tools, such as, for instance, Program of Research on Integration of Services for the Maintenance of Autonomy 7 (PRISMA 7), the gold standard tool of Fried criteria, is somehow problematic since the question referring to physical activity originates from a questionnaire that has not been translated and validated, while Clinical Frailty Scale (CFS) has been validated for translation but not for the capacity to detect frailty. The aim of this study is to validate these tools for their accuracy to detect frailty by using a measurable index of frailty, previously proposed for use in clinical studies: the Short Physical Performance Battery (SPPB). Seventy-four male and female participants (mean age 80.47 years SD = ±7.45 years, minimum-maximum age = 65-95) have been evaluated for their frailty status using different tools. We observed that the PRISMA 7 translation detects frailty only when one question is removed at a cut-off of ≥2 and indicates a sensitivity of 88.1% and specificity of 99.9% with a good correlation with SPPB measurements (r = -0.858; p < 0.001). When CFS was validated using SPPB, it demonstrated a very good correlation (r = -0.838; p < 0.001 respectively) as was the case for the modified Fried Criteria (r = -0.725; p < 0.001). All items demonstrated a good correlation between them. We here propose that we can accurately assess frailty status in the community setting by using a modified version of Fried criteria, Clinical Frailty Scale translation in Greek, and we can screen for frailty by using the Greek translation of PRISMA 7 only after removing item 6 of the questionnaire.

Factors Associated with Frailty in Older Adults in Community and Nursing Home Settings: A Systematic Review with a Meta-Analysis

Background: Frailty is a globally recognized issue. However, there is a lack of evidence exploring factors associated with frailty among older residents in community and nursing-home settings. Methods: To explore the prevalence and factors associated with frailty among older adults in community and nursing-home settings, we conducted a systematic search following the PRISMA guidelines across Web of Science, MEDLINE, EMBASE, PubMed, and Cochrane databases up until January 2024, selecting 38 studies which encompassed 150,642 participants. Results: Our findings showed higher frailty prevalence in nursing homes compared to communities. Frailty was significantly associated with sociodemographic (living alone, poor self-reported health), physiological (poor sleep, low activity of daily living), behavioral (physical inactivity) and disease (chronic conditions, depression) factors in both community and nursing-home settings. Conclusions: There are numerous factors associated with frailty in older adults in nursing-home and community settings. These factors underscore the significance of promptly identifying high-risk individuals and devising appropriate interventions to mitigate frailty among them.

Relationship between the severity of pre-frailty and the degree of adaptation of Ninjin'yoeito (NYT) on pre-frailty

With the global trend towards longer life expectancies, there's an increasing emphasis on not just living longer, but also maintaining health and wellbeing into older age. This study explores the efficacy of Ninjin'yoeito (NYT) in the early stages of frailty, a critical period for preventive interventions. Taking account of the knowledge gap regarding the association between early frailty and NYT, we use data from workplace health checkups to examine the relationship between pre-frailty severity and NYT adaption. The objective of our research is to enhance the comprehension of early treatments using NYT to prevent the progression of frailty. A total of 314 employees of the Kyoto Industrial Health Association who received workplace health checkups between November 2021 and March 2023 and consented to this study were included in the analysis. Information on gender, age, body mass index (BMI), NYT-specific symptoms assessment, the Japanese version of the General Health Questionnaire-12 (GHQ-12), and the Kihon Checklist (KCL) were obtained. The correlation analysis revealed that there was a strong positive correlation between the number of applicable NYT indications and the GHQ-12 score (r = 0.5992, p < 0.0001). Similarly, a moderate positive correlation was observed between the number of applicable NYT indications and the KCL score (r = 0.5030, p < 0.0001). In the multivariate analysis, both GHQ-12 (β = 0.49, SE = 0.06, t = 7.66, 95% CI: 0.36 to 0.62, p = 0.000) and KCL (β = 0.54, SE = 0.12, t = 4.29, 95% CI: 0.29 to 0.79, p = 0.000) showed significant positive associations with the variance in the number of applicable NYT indications, indicating that higher scores on these measures were related to a greater number of indications. NYT has the potential to be utilized not only as a therapeutic intervention for frailty, but also as a preventive measure.

Effect modification of polypharmacy on incident frailty by chronic kidney disease in older adults

BACKGROUND

Frailty and polypharmacy are common conditions in older adults, especially in those with chronic kidney disease (CKD). Therefore, we analyzed the association of polypharmacy and incident frailty and the effect modification by CKD in very old adults.

METHODS

In non-frail individuals within the Berlin Initiative (cohort) Study, polypharmacy (≥ 5 medications) was assessed according to multiple definitions based on the number of regular and on demand prescription and over the counter drugs, as well as vitamins and supplements. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73m2 and/or an albumin-creatinine ratio ≥ 30 mg/g. Incident frailty was assessed at follow-up using Fried criteria. Logistic regression was applied to assess (1) the association of different polypharmacy definitions with incident frailty and (2) effect modification by CKD.

RESULTS

In this cohort study, out of 757 non-frail participants (mean age 82.9 years, 52% female, 74% CKD), 298 (39%) participants reported polypharmacy. Over the observation period of 2.1 years, 105 became frail. Individuals with polypharmacy had 1.96 adjusted odds (95% confidence interval (CI): 1.20-3.19) of becoming frail compared to participants without polypharmacy. The effect of polypharmacy on incident frailty was modified by CKD on the additive scale (relative excess risk due to interaction: 1.56; 95% CI 0.01-3.12).

CONCLUSIONS

This study demonstrates an association of polypharmacy and incident frailty and suggests strong evidence for an effect modification of CKD on polypharmacy and incident frailty. Revision of prescriptions could be a target strategy to prevent frailty occurrence, especially in older adults with CKD.

Influence of chronic medical conditions on older patients' willingness to deprescribe medications: a cross-sectional study

BACKGROUND

Aging correlates with a heightened prevalence of chronic diseases, resulting in multimorbidity affecting 60% of those aged 65 or older. Multimorbidity often leads to polypharmacy, elevating the risk of potentially inappropriate medication (PIM) use and adverse health outcomes. To address these issues, deprescribing has emerged as a patient-centered approach that considers patients' beliefs and attitudes toward medication and reduces inappropriate polypharmacy in older adults. Our study aims to investigate whether certain chronic medical conditions are associated with older patients' willingness to deprescribe medications.

METHODS

A cross-sectional study enrolled 192 community-dwelling individuals aged 65 or older taking at least one regular medication. Data included demographics, clinical characteristics, and responses to the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics characterized participants, while multiple binary logistic regression identified associations between chronic medical conditions and willingness to deprescribe.

RESULTS

Among the participants (median age: 72 years, 65.6% female), 91.6% had multimorbidity. The analysis revealed that willingness to deprescribe significantly increased with the presence of gastric disease (adjusted odds ratio [aOR] = 4.123; 95% CI 1.221, 13.915) and age (aOR = 1.121; 95% CI 1.009, 1.246). Conversely, prostatic pathology (aOR = 0.266; 95% CI 0.077, 0.916), higher scores in the rPATD appropriateness factor (aOR = 0.384; 95% CI 0.190, 0.773), and rPATD concerns about stopping factor (aOR = 0.450; 95% CI 0.229, 0.883) diminished patients' willingness to deprescribe.

CONCLUSIONS

This study highlights the intricate relationship between older patients' attitudes toward deprescribing and chronic medical conditions. We found that gastric disease was associated with an increased willingness to deprescribe medications, while prostate disease was associated with the opposite effect. Future research should explore how patients with specific diseases or groups of diseases perceive deprescribing of medications general and for specific medications, aiding in the development of targeted interventions.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Polypharmacy and risk of fractures in older adults: A systematic review

BACKGROUND

Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association.

METHODS

We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, abstracts, and full texts, then performed data extraction and quality assessment.

RESULTS

Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose-response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high.

CONCLUSIONS

Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.

Types, predictors, and consequences of medicines related problems (MRPs) in frail older adults admitted to hospital from primary care - A retrospective cohort study

Introduction

Medicines related problems (MRPs) can be common in frail older people due to age-compromised body systems and a propensity to be on multiple drugs concurrently. This group of people can also succumb to a rapid deterioration in health. Thus, it is important to investigate MRPs in frail older people. The objectives of the study were to evaluate prevalence of MRPs, types of MRPs, risk factors and deterioration that can be associated with MRPs in frail older people admitted to an English teaching hospital from primary care.

Methods

Included in the sample were frail older adults, aged 65 years and over, admitted from primary care. Data was retrieved from the hospital's electronic patient record system, anonymised, and reviewed for MRPs. MRPs which were retrospectively identified at admission were coded with the WHO-ICD10,2016 (World Health Organisation-International Classification of Diseases version 10, 2016). Descriptive and inferential statistics were performed on the data using SPSS Version 25. Primary outcome was the prevalence of MRPs in frail older patients. Secondary outcome was the association of deterioration indicated as fall, delirium, or NEWs ≥3 with presence of MRPs.

Results

Among the 507 frail older people (≥4 on Rockwood scale) that met criteria for inclusion, 262 (51.8%) were patients with MRPs and 244 (48.2%) without. The Median age of sample as a whole was 85 years (IQR = 80-89). Prevalence of MRPs was 33.28%. Types of MRPs were adverse drug reaction (ADR-20%), non-compliance (9.1%), unintentional poisoning (3.3%) and inappropriate polypharmacy (0.8%). In logistic regression, potentially inappropriate medicines (PIM), social support, number of comorbidities and winter were significant predictors of MRPs. Risk of deteriorating with delirium was two times higher in patients with MRPs than in patients without MRPs, RR 2.613 (95% CI, 1.049 to 6.510).

Conclusion

MRPs and risks of deterioration associated with MRPs in frail older people can be reduced. This is because factors associated with MRPs can be modified.

Polypharmacy in Older Patients: A Three-Year Longitudinal Analysis in Primary Care Settings of Aragón, Spain

BACKGROUND

Challenges of polypharmacy and the impact of coronavirus disease 2019 (COVID-19) pandemic in older patients require further investigation. This retrospective study analyzed the progression of polypharmacy and anticholinergic burden in older patients in a primary care setting before, during, and after the COVID-19 pandemic.

METHODS

This 3-year cross-sectional study (2019, 2020, and 2021) comprised a dynamic cohort of individuals aged ≥75 years, who attended the Arrabal Primary Care Center in Zaragoza, Spain. Older patients with polypharmacy (≥5 medications) were identified according to their electronic health records. We collected demographic and clinical data, including medication prescriptions, diagnoses, and anticholinergic risks, and performed descriptive and statistical analyses.

RESULTS

This study included a total of 1,928 patients with a mean age of 83.52±0.30 years. Over the 3-year study period, the mean number of medications prescribed increased, from 9.4 in 2019 to 10.4 in 2021. The prevalence of excessive polypharmacy (≥10 medications) increased from 39% in 2019 to 45% in 2021. The most commonly prescribed drugs were anilides, proton pump inhibitors, benzodiazepine derivatives, and platelet aggregation inhibitors. Women had a higher prevalence of illnesses and anticholinergic drug prescriptions than men.

CONCLUSION

The results of this study highlighted an upward trend in polypharmacy and excessive polypharmacy among older patients in primary care settings. Future research should focus on optimizing medication management and deprescribing strategies and minimizing the adverse effects of polypharmacy in this population.

A Herbal Prescription of Insamyangyeongtang as a Therapeutic Agent for Frailty in Elderly: A Narrative Review

Frailty is a major geriatric syndrome with a multifactorial etiology that induces a decline in multiple physiological and psychological functions. In traditional East Asian medicine (TEAM), qi and blood deficiency clinically represent as fatigue, anemia, anorexia, decreased strength after illness, and weakness, commonly interpretated as frailty. An herbal prescription of Insamyangyeongtang (IYT, Ninjin'yoeito in Japanese, Ren-Shen-Yang-Rong-Tang in Chinese) tonifies qi and blood and has the potential to treat multiple targets caused by qi and blood deficiency. As the population ages and frailty increases, there is an increase in the potential effectiveness of IYT in frailty. This study reviewed relevant clinical trials to provide an updated view on the effect of IYT on frailty. IYT has therapeutic effects on frailty associated with chronic respiratory diseases (e.g., chronic obstructive pulmonary disease) and cognitive impairments (e.g., Alzheimer's disease) and improves respiratory symptoms and cognition. IYT also has therapeutic effects on weight gain, muscle mass, and strength, and improves nutritional status in frail elderly individuals who have decreased muscle mass and strength, loss of appetite, and weight loss. The same effect has been shown in frailty in elderly individuals with rehabilitation treatment and chronic diseases. IYT also improves frailty associated with symptoms such as intractable dizziness and genitourinary symptoms. The beneficial effects of IYT in several diseases could be important for medication replacement, reduction, and prevention of polypharmacy. Based on the results of this review, we suggest that IYT has the potential to be a therapeutic agent against frailty.

Associations of polypharmacy with frailty severity and each frailty phenotype in community-dwelling older adults: Itabashi Longitudinal Study on Aging

AIM

Although polypharmacy and frailty are concerns in older adults, there is limited understanding of their association, particularly regarding frailty severity and its phenotypes within this population. This study aimed to examine the association between polypharmacy and frailty severity or frailty phenotypes in community-dwelling older Japanese adults.

METHODS

This cross-sectional study included 1021 older adults from the Itabashi Longitudinal Study on Aging. Men accounted for 45.4%, and the mean age (standard deviation) was 77.9 (5.1) years. Participants were classified into frail (n = 67), pre-frail (n = 543), and robust (n = 411) groups using the revised Japanese Cardiovascular Health Study criteria. Polypharmacy was defined as using five or more self-reported prescription drugs. Ordinal and binomial logistic regression analyses examined the association between polypharmacy and frailty severity or frailty phenotypes (weight loss, weakness, exhaustion, slowness, and low activity). These models were adjusted for age, sex, body mass index, number of comorbidities, living status, employment status, years of education, as well as drinking and smoking habits.

RESULTS

The prevalence of frailty in participants with and without polypharmacy was 10.1% and 5.0%, respectively. Participants with polypharmacy were more likely to have frailty (adjusted odds ratio [95% confidence interval], 1.89 [1.40-2.57]), weight loss (1.81 [1.00-3.27]), weakness (1.50 [1.08-2.09]), and slowness (2.25 [1.29-3.94]) compared with the no-polypharmacy group.

CONCLUSIONS

Polypharmacy was associated with frailty severity and three frailty phenotypes. Longitudinal studies are required to investigate whether polypharmacy can predict the development and progression of frailty. Geriatr Gerontol Int 2024; 24: 196-201.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project

Background

Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs.

Methods

A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed.

Results

A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively.

Conclusion

Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.

Prevalence of depression and clinical depressive symptoms in community-dwelling older adults with cognitive frailty

AIM

The present study determines the prevalence of depression and the extent of clinical depression symptoms among community-dwelling older adults with cognitive frailty and its associated factors.

METHODS

A total of 755 older adults aged ≥60 years were recruited. Their cognitive performance was determined using the Clinical Dementia Rating. Fried's criteria was applied to identify physical frailty, and the Beck Depression Inventory assessed their mental states.

RESULTS

A total of 39.2% (n = 304) of the participants were classified as cognitive frail. In this cognitive frail subpopulation, 8.6% (n = 26) had clinical depressive symptoms, which were mostly somatic such as disturbance in sleep pattern, work difficulty, fatigue, and lack of appetite. Older adults with cognitive frailty also showed significantly higher depression levels as compared with the noncognitive frail participants (t (622.06) = -3.38; P = 0.001). There are significant associations between depression among older adults with cognitive frailty and multimorbidity (P = 0.009), polypharmacy (P = 0.009), vision problems (P = 0.046), and hearing problems (P = 0.047). The likelihood of older adults with cognitive frailty who experience impairments to their vision and hearing, polypharmacy, and multimorbidity to be depressed also increased by 2, 3, 5, and 7-fold.

CONCLUSIONS

The majority of the Malaysian community-dwelling older adults were in a good mental state. However, older adults with cognitive frailty are more susceptible to depression due to impairments to their hearing and vision, multimorbidity, and polypharmacy. As common clinical depressive symptoms among older adults with cognitive frailty are mostly somatic, it is crucial for health professionals to recognize these and not to disregard them as only physical illness. Geriatr Gerontol Int 2024; 24: 225-233.

All-Cause Death and Major Adverse Events in Atrial Fibrillation with Frailty: Observations from the Korea National Health Insurance Service Data

Background

Atrial fibrillation (AF) is an indicator of frailty in old patients. This study aimed to investigate the effect of frailty on the use of oral anticoagulants (OAC) and clinical outcomes in a nationwide cohort of patients with new-onset AF.

Methods

This study included 451,368 participants without AF from the Korea National Health Insurance Service-Health Screening cohort between 2002 and 2009. The Hospital Frailty Risk Score was retrospectively calculated for each patient using all available International Classification of Disease 10th revision diagnostic codes. According to the aggregate score, patients were divided into two groups: the participants without frailty ( < 5 points) and the participants with frailty ( ≥ 5 points). The primary outcome was death from any cause, and the secondary outcomes were cardiovascular death, ischemic stroke, major bleeding, and heart failure admission.

Results

With up to 7.2 ± 1.5 years of follow-up, 11,953 participants (median age, 67 [interquartile range, 59.5-74.5] years; 7200 [60.2%] males) developed new-onset AF. Among the patients with AF, 3224 (26.9%) had frailty. Frailty was significantly associated with old age, female sex, polypharmacy, and other comorbidities. In patients with AF, frailty was negatively associated with OAC prescription after new-onset AF (p < 0.001). Compared to patients without frailty, patients with frailty had a significantly higher incidence and risk of all-cause death (hazard ratio [HR] 2.88, 95% confidence interval [CI] 2.65-3.14), cardiovascular death (HR 2.42, 95% CI 2.10-2.80), ischemic stroke (HR 2.25, 95% CI 2.02-2.51), major bleeding (HR 2.44, 95% CI 2.17-2.73), and heart failure admission (HR 1.29, 95% CI 1.09-1.52). In subgroup analysis, when compared to the non-OAC group, the risks associated with frailty were significantly lower in the OAC group for all-cause death, cardiovascular death, ischemic stroke, and heart failure admission.

Conclusions

Frailty was negatively associated with the use of OAC and was a predictor of poor prognosis owing to the association of frailty with death, thromboembolic events, bleeding, and heart failure admission. However, OAC use was associated with lower risks related to frailty for all-cause death and major adverse cardiovascular events in patients with AF.

Polypharmacy and Associated Health Outcomes in the PARI-HD Study

Background

A growing body of evidence points to potential risks associated with polypharmacy (using ≥5 medications) in older adults, but most evidence is derived from studies where racial and ethnic minorities remain underrepresented among research participants.

Objective

Investigate the association between polypharmacy and cognitive function, subjective health state, frailty, and falls in Hispanic older adults.

Methods

Panama Aging Research Initiative-Health Disparities (PARI-HD) is a community-based cohort study of older adults free of dementia at baseline. Cognitive function was measured with a neuropsychological test battery. Frailty assessment was based on the Fried criteria. Subjective health state and falls were self-reported. Linear and multinomial logistic regression analyses were used to examine association.

Results

Baseline evaluations of 468 individuals with a mean age of 69.9 years (SD = 6.8) were included. The median number of medications was 2 (IQR: 1-4); the rate of polypharmacy was 19.7% (95% confidence interval [CI] = 16.1-23.3). Polypharmacy was inversely associated with self-rated overall health (b =-5.89, p < 0.01). Polypharmacy users had 2.3 times higher odds of reporting two or more falls in the previous 12 months (odds ratio [OR] = 2.31, 95% CI = 1.06-5.04). Polypharmacy was independently associated with Fried's criteria for pre-frailty (OR = 2.90, 95% CI = 1.36-5.96) and frailty (OR = 5.14, 95% CI = 1.83-14.42). Polypharmacy was not associated with cognitive impairment.

Conclusions

These findings illustrate the potential risks associated with polypharmacy among older adults in Panama and may inform interventions to improve health outcomes in this population.

Problems experienced when swallowing solid oral dosage forms in older Japanese patients with dysphagia: A cross-sectional study

AIMS

We aimed to assess the difficulty in taking solid oral dosage forms (SODFs) among older people with dysphagia and clarify the relationship between difficulty in swallowing SODFs and swallowing function.

METHODS AND RESULTS

Outpatients from a dysphagia clinic aged ≥65 years were asked yes-or-no questions about the applicability of eight items regarding difficulty in taking SODFs. Additionally, a videofluorographic swallowing study (VFSS) was performed to assess their swallowing function. The Kruskal-Wallis test and Spearman's rank correlation coefficient were used to analyze the relationship between difficulty in taking SODFs and swallowing function.

RESULTS

Among the 93 participants, the average number of SODFs consumed was 5.8 ± 3.1. In the questionnaire, the average number of "yes" answers was 2.2 ± 2.2, and 65 patients (71.0%) answered "yes" to at least one question. Additionally, no significant relationship was observed between the perceived difficulty in swallowing SODFs and VFSS findings.

CONCLUSION

Approximately 70% of participants reported subjective difficulty in taking SODFs, showing that patients uniformly reported perceived difficulty in taking SODFs regardless of actual swallowing function. The results of this study suggest that patients must be questioned thoroughly about their SODFs use, regardless of the objective severity of their dysphagia.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

Relationship between chronic pain, depressive symptoms, and functional disability in community-dwelling older adults: mediating role of frailty

BACKGROUND

Borim et al. showed that older adults with chronic pain exhibited more depressive symptoms and frailty components. Depressive symptoms were associated with more frailty components, and those with more depressive symptoms and frailty faced greater limitations in IADL performance. Frailty appears to mediate the pathway from chronic pain to functional impairment Chronic pain is directly associated with depressive symptoms and frailty. Chronic pain is not directly associated with functional disability. Depression and frailty are both directly associated with functional disabilities. Frailty mediates the association between chronic pain and functional disability. Depression; Disability evaluation; Frailty; Frail elderly.

OBJECTIVE

To evaluate the direct and indirect effects of chronic pain, depressive symptoms, frailty components, and functional disability through a pathway analysis approach in a sample of community-dwelling older adults.

METHODS

Data of 419 participants were cross-sectionally evaluated for the presence of depressive symptoms (Geriatric Depression Scale [15 items]), physical frailty components (phenotype criteria), chronic pain, and limitations in performing instrumental activities of daily living (functional disability scale by Lawton and Brody). Structural equation modeling via path analysis was used to explore the direct and indirect effects among these four variables. Statistical significance was set at p<0.05.

RESULTS

Of the total participants, 69.8% were women and 59.3% had low education (1-4 years); the mean age was 80.3±4.6 years. Chronic pain and depressive symptoms were directly related and were associated to frailty. The number of frailty components and depressive symptoms were directly associated with functional disability. Frailty had an indirect effect on the association between chronic pain, depressive symptoms, and functional disabilities.

CONCLUSION

The pathway from chronic pain and depressive symptoms to functional disability is potentially mediated by the number of frailty components.

Polypharmacy and Antibody Response to SARS-CoV-2 Vaccination in Residents of Long-Term Care Facilities: The GeroCovid Vax Study

BACKGROUND AND OBJECTIVE

Polypharmacy is common in older adults, particularly among those living in long-term care facilities. This condition represents a marker of clinical complexity and might directly affect the immunological response. However, there are limited data on the association of polypharmacy with vaccine immunogenicity. This study evaluated the immune response to anti-SARS-CoV-2 vaccines in older residents of long-term care facilities as a function of the number of medications used.

METHODS

In 478 long-term care facility residents participating in the GeroCovid Vax study, we assessed SARS-CoV-2 trimeric S IgG levels through chemiluminescent assays before the vaccination and after 2, 6, and 12 months. A booster dose was administered between 6- and 12-month assessments. Sociodemographic information and data on chronic diseases and medications were derived from medical records. Based on the number of daily medications, residents were classified into the no polypharmacy (zero to four medications), polypharmacy (five to nine medications), and hyperpolypharmacy (ten or more medications) groups.

RESULTS

In the sample (mean age 82.1 years, 69.2% female), 200 (41.8%) residents were taking five or fewer medications/day (no polypharmacy), 229 (47.9%) had polypharmacy, and 49 (10.3%) had hyperpolypharmacy. Using linear mixed models adjusted for potential confounders, we found that hyperpolypharmacy was associated with a steeper antibody decline after 6 months from the first vaccine dose administration (β = - 0.29, 95% confidence interval - 0.54, - 0.03, p = 0.03) than no polypharmacy, while no significant differences were observed at 12 months.

CONCLUSIONS

The humoral immune response to SARS-CoV-2 vaccination of older residents showed only slight changes as a function of the number of medications taken. Although it seemed less durable among older residents with hyperpolypharmacy, the booster dose administration equalized such a difference.

Predictors of older patients' willingness to have medications deprescribed: A cross-sectional study

BACKGROUND

Deprescribing is a complex process requiring a patient-centred approach. One frequently expressed deprescribing barrier is patients' attitudes and beliefs towards deprescribing. This study aimed to identify the predictors of patients' willingness to have medications deprescribed.

METHODS

A cross-sectional study was conducted with community-dwelling patients aged ≥65 who are taking at least one regular medication. Data collection included patients' demographic and clinical characteristics and the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics were used to present the patients' characteristics. Multiple binary logistic regression analysis was performed to identify the predictors of the patients' willingness to have medications deprescribed.

RESULTS

One hundred ninety-two participants (median age 72 years; 65.6% female) were included. Most (83.33%) were willing to have medications deprescribed, and the predictors were age (adjusted odds ratio [aOR] = 1.136; 95% CI 1.026, 1.258), female sex (aOR = 3.036; 95% CI 1.059, 8.708) and the rPATD concerns about stopping factor (aOR = 0.391; 95% CI 0.203, 0.754).

CONCLUSIONS

Most patients were willing to have their medications deprescribed if it is recommended by their doctors. Older age and female sex increased the odds of willingness to deprescribe; higher concerns about stopping medications decreased the odds. These findings suggest that addressing patients' concerns about stopping their medicines may contribute to deprescribing success.

Gender-specific linkages: frailty, polypharmacy, anti-cholinergic burden, and 5-year mortality risk-a real-world analysis

Background

With higher age, frailty escalates the risk of falls, unexpected physical dysfunction, hospitalization, and mortality. Polypharmacy in the older population is a major challenge that not only increases medical costs, but also may worsen the risk of hospitalization and death. More importantly, the properties of anti-cholinergic drugs contribute various negative effects. This study aimed to investigate the sex difference in the association of polypharmacy, anticholinergic burden, and frailty with mortality.

Methods

Participants older than 65 years who attended the geriatric outpatient clinic of the study center between January 2015 and July 2020 were invited to participate in this retrospective study. Comprehensive geriatric assessment data were collected and the phenotype of frailty was determined by Fried's criteria. Cox regression and the Kaplan-Meier curve were used to identify risk factors of 5-year survival along with intergroup differences in the risks.

Results

Of the 2,077 participants, 47.5% were female. The prevalence of frailty and the rate of polypharmacy were 44.7% and 60.6%, respectively. Higher age, male sex, low body mass index, low Mini-Mental State Examination scores, low activities of daily living, frailty status, polypharmacy, and a high Charlson Comorbidity Index score, and greater anticholinergic burden were significant risk factors that were associated with the 5-year all-cause mortality. Male patients with frailty exhibited the highest risks of mortality compared with male patients without frailty and female patients with or without frailty. Polypharmacy was significantly associated with a higher 5-year mortality rate in the frail male group compared with the non-frail male. In frail female group, individuals with a higher anticholinergic burden (as indicated by the Anticholinergic Cognitive Burden Scale) from drug usage exhibited an elevated 5-year mortality rate.

Conclusions

Polypharmacy and greater anticholinergic burden, synergistically interacted with frailty and intensified the 5-year mortality risk in a gender-specific manner. To mitigate mortality risks, clinicians should prudently identify polypharmacy and anticholinergic burden in the older population.

Cocoa Polyphenols Prevent Age-Related Hearing Loss and Frailty in an In Vivo Model

Age-related hearing loss (ARHL) impairs the quality of life in elderly persons. ARHL is associated with comorbidities, such as depression, falls, or frailty. Frailty syndrome is related to poor health outcomes in old age. ARHL is a potentially modifiable risk factor for frailty. Oxidative stress has been proposed as a key factor underlying the onset and/or development of ARHL and frailty. Cocoa has high levels of polyphenols and provides many health benefits due to its antioxidant properties. Male and female C57Bl/6J mice were randomly assigned to two study groups: animals receiving a cocoa-supplemented diet and the other receiving a standard diet. Then, at the ages of 6, 14, and 22 months, hearing and frailty were measured in all mice. Auditory steady-state responses (ASSR) threshold shifts were measured to different frequencies. The frailty score was based on the "Valencia Score" adapted to the experimental animals. The total antioxidant capacity and total polyphenols in urine samples were also measured. Significant improvements in hearing ability are observed in the cocoa groups at 6, 14, and 22 months compared to the no cocoa group. The cocoa diet significantly retards the development of frailty in mice. Cocoa increases the concentration of polyphenols excreted in the urine, which increases the total antioxidant capacity. In conclusion, cocoa, due to its antioxidant properties, leads to significant protection against ARHL and frailty.

Potentially inappropriate medication and frailty in older adults: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess existing studies to demonstrate the association between potentially inappropriate medication (PIM) and frailty.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched major electronic databases (PubMed, Web of Science, the Cochrane Library, Embase, CINHAL, PsycInfo, China National Knowledge Infrastructure, China Biology Medicine disk, Weipu, and Wanfang) from their inception until February 25, 2023 (data updated on May 4, 2023), for observational studies investigating PIM and frailty. I2 was used to measure the heterogeneity between studies quantitatively. A random effect model calculated pooled effect size owing to high heterogeneity. Subgroup analysis was conducted to explore sources of heterogeneity. Additionally, the studies' quality was evaluated using the Newcastle Ottawa Scale (a modified Newcastle Ottawa Scale was used to evaluate cross-sectional studies).

RESULTS

Twenty-four studies were included for systematic review, 14 of which were included in the meta-analysis. After pooling the effect size, the odds ratio with PIM as the dependent variable was 1.12 (95%CI: 1.01-1.25), and that with frailty as the dependent variable was 1.75 (95%CI: 1.25-2.43), indicating a bidirectional association between PIM and frailty.

CONCLUSIONS

PIM and frailty interact with each other and have a bidirectional association, thus providing additional information for early clinical identification and prevention of frailty, and medication safety management.

Insight into Risk Factors, Pharmacogenetics/Genomics, and Management of Adverse Drug Reactions in Elderly: A Narrative Review

The European Medicine Agency (EMA) has defined Adverse Drug Reactions (ADRs) as "a noxious and unintended response to a medicine", not including poisoning, accidental, or intentional overdoses. The ADR occurrence differs based on the approach adopted for defining and detecting them, the characteristics of the population under study, and the research setting. ADRs have a significant impact on morbidity and mortality, particularly among older adults, and represent a financial burden for health services. Between 30% and 60% of ADRs might be predictable and preventable, emerging as a result of inappropriate prescription, drug chemistry inherent toxicity, cell-specific drug toxicity, age- and sex-related anomalies in drug absorption, distribution, metabolism, and elimination (ADME), and drug-drug interactions (DDIs) in combination therapies or when a patient is treated with different drugs for concomitant disorders. This is particularly important in chronic diseases which require long-term treatments. Rapid developments in pharmacogenetics/genomics have improved the understanding of ADRs accompanied by more accurate prescriptions and reduction in unnecessary costs. To alleviate the burden of ADRs, especially in the elderly, interventions focused on pharmaceutical principles, such as medication review and reconciliation, should be integrated into a broader assessment of patients' characteristics, needs, and health priorities. Digital health interventions could offer valuable solutions to assist healthcare professionals in identifying inappropriate prescriptions and promoting patient adherence to pharmacotherapies.

Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study

INTRODUCTION

Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source.

AIM

To develop a list of medications to facilitate appropriate prescribing among older adults.

METHODS

A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians.

RESULTS

The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains.

CONCLUSIONS

The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Association between number of medications and hip fractures in Japanese elderly using conditional logistic LASSO regression

To examine the association between hip fracture and associated factors, including polypharmacy, and develop an optimal predictive model, we conducted a population-based matched case-control study using the health insurance claims data on hip fracture among Japanese patients. We included 34,717 hospitalized Japanese patients aged ≥ 65 years with hip fracture and 34,717 age- and sex- matched controls who were matched 1:1. This study included 69,434 participants. Overall, 16 variable comorbidities and 60 variable concomitant medications were used as explanatory variables. The participants were added to early elderly and late elderly categories for further analysis. The odds ratio of hip fracture increased with the number of medications only in the early elderly. AUC was highest for early elderly (AUC, 0.74, 95% CI 0.72-0.76). Use of anti-Parkinson's drugs had the largest coefficient and was the most influential variable in many categories. This study confirmed the association between risk factors, including polypharmacy and hip fracture. The risk of hip fracture increased with an increase in medication number taken by the early elderly and showed good predictive accuracy, whereas there was no such association in the late elderly. Therefore, the early elderly in Japan should be an active target population for hip fracture prevention.

Benefits of deprescribing for older people with frailty and polypharmacy: part one

The UK population is ageing rapidly, a trend that is likely to continue due to improvements in chronic disease management and increased life expectancy. Comorbidities, including frailty, become increasingly common with age and as a result it is likely that multiple medicines will be prescribed for older people, leading to polypharmacy. This is a concern because polypharmacy is associated with various adverse effects and an increased medicine burden in this population, as well as a financial burden for the healthcare system. This article, the first of two parts, explains the physiology of ageing and frailty, and considers the adverse effects of polypharmacy on older people with frailty, using a fictional case study to illustrate this. Part two will use the case study to explore the use of medication reviews and deprescribing benefits as part of medicines optimisation.

Frailty and Polypharmacy in Primary Care

INTRODUCTION

The Clinical Frailty Scale (CFS) is a clinical judgement-based frailty tool developed from the Canadian Study of Health and Aging. Many studies on the measurement of frailty and its effect on clinical outcomes have been conducted on patients hospitalized, especially in intensive care units. The purpose of this study is to examine the relationship between polypharmacy and frailty on outpatient older adult patients in primary care.

MATERIALS AND METHOD

This cross-sectional study included 298 patients who were aged ≥65 years and admitted to Yenimahalle Family Health Center between May-2022 and July-2022. Frailty was evaluated by using CFS. Polypharmacy was defined as five medications or more and "excessive polypharmacy" as 10 medications or more. The medications below five are grouped as "no polypharmacy".

RESULTS

There was a statistically significance between age groups, gender, smoking status, marital status, polypharmacy status, and FS (p = .003 and η2: .20; p < .001 and Cohen d: .80; p = .018 and Cohen d: .35; p < .001 and Cohen d: 1.10 and p < .001 and η2: 1.45 respectively). A strong, positive correlation was found between polypharmacy and the frailty score.

CONCLUSION

Polypharmacy, especially excessive polypharmacy, may be a promising adjunct to frailty in identifying older patients whose health is more likely to worsen. Providers in primary care should also consider frailty when prescribing drugs.

Preoperative evaluation of the elderly patient

Nowadays, the pre-operative evaluation of older patients is a critical step in the decision-making process. Clinical assessment and care planning should be considered a whole process rather than separate issues. Clinicians should use validated tools for pre-operative risk assessment of older patients to minimize surgery-related morbidity and mortality and enhance care quality. Traditional pre-operative consultation often fails to capture the pathophysiological and functional profiles of older patients. The elderly's pre-operative evaluation should be focused on determining the patient's functional reserve and reducing any possible peri-operative risk. Therefore, older adults may benefit from the Comprehensive Geriatric Assessment (CGA) that allows clinicians to evaluate several aspects of elderly life, such as depression and cognitive disorders, social status, multi-morbidity, frailty, geriatric syndromes, nutritional status, and polypharmacy. Despite the recognized challenges in applying the CGA, it may provide a realistic risk assessment for post-operative complications and suggest a tailored peri-operative treatment plan for older adults, including pre-operative optimization strategies. The older adults' pre-operative examination should not be considered a mere stand-alone, that is, an independent stage of the surgical pathway, but rather a vital step toward a personalized therapeutic approach that may involve professionals from different clinical fields. The aim of this review is to revise the evidence from the literature and highlight the most important items to be implemented in the pre-operative evaluation process in order to identify better all elderly patients' needs.

Spreading Senescent Cells' Burden and Emerging Therapeutic Targets for Frailty

The spreading of senescent cells' burden holds profound implications for frailty, prompting the exploration of novel therapeutic targets. In this perspective review, we delve into the intricate mechanisms underlying senescent cell spreading, its implications for frailty, and its therapeutic development. We have focused our attention on the emerging age-related biological factors, such as microbiome and virome alterations, elucidating their significant contribution to the loss of control over the accumulation rate of senescent cells, particularly affecting key frailty domains, the musculoskeletal system and cerebral functions. We believe that gaining an understanding of these mechanisms could not only aid in elucidating the involvement of cellular senescence in frailty but also offer diverse therapeutic possibilities, potentially advancing the future development of tailored interventions for these highly diverse patients.

Cognitive and functional trajectories in geriatric outpatients after a pharmacologic multidisciplinary intervention: A study protocol

BACKGROUND

Polypharmacy is a common condition among older adults and is associated with adverse drug reactions and health outcomes, including falls, functional and cognitive impairment, and frailty.

METHODS

A prospective observational study will be conducted on older adults with polypharmacy. The aim is to assess the impact of a specialized outpatient clinic focused on pharmacotherapy optimization recently integrated into daily clinical practice in a Spanish public tertiary teaching hospital on patients' functional and cognitive abilities. Patients who attend a first consultation and meet inclusion criteria (≥75 years old, have a life expectancy≥3 months, and polypharmacy (≥5 prescribed medications) will be invited to participate in the study, until reach a calculated sample size of 104 participants. Patients will be excluded if they are enrolled in a clinical trial related to medication or in the event of a no-show or cancellation of the appointment at the first visit. Participants will receive usual care: a first consultation including multidisciplinary pharmacological optimization in the context of a CGA and subsequent face-to-face and/or telephone follow-up (∼3 and ∼6 months). The primary endpoint will be the functional (Barthel index) and cognitive change in capacities (IPCR - Índice de Incapacidad psíquica de la Cruz Roja). Secondary endpoints include medication changes, changes in patients' quality of life, rate of falling, and use of healthcare resources.

DISCUSSION

We expect that the close collaboration between professionals from different disciplines working together will be an effective strategy to improve the functional and cognitive abilities of older adults.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05408598 (March 1, 2022).

Baseline Profiles of Drug Prescriptions Prior to Diagnosis of Mild Cognitive Impairment (MCI) Obtained by Latent Class Analysis (LCA), and Assessment of Their Association with Conversion to Dementia

Polypharmacy has been linked to cognitive decline. However, interventions targeting modifiable risk factors, some of which are targets of the most commonly used drugs, could reduce the prevalence of dementia. Our aim was to determine the drug prescription regimen at baseline, prior to the diagnosis of mild cognitive impairment (MCI), and its possible association with progression to dementia. Data were collected from the electronic medical records of 342 MCI outpatients diagnosed during 2006-2017 at their first neurology consultation. We followed the classical three-step method of statistical analysis, starting with a Latent Class Analysis (LCA) to discover subgroups of drug prescription probability. Half of the patients were under polypharmacy (≥5 drugs), 17.5% had no recorded medication, 33.3% progressed to dementia (94.7% in ≤5 years), and 84.1% of them to Alzheimer's disease (AD). According to the LCA and based on 20 therapeutic indicators obtained from 240 substances and regrouped according the Anatomical Therapeutic Chemical Classification, we identified a four-profile model: (1) low (35.7% of patients); (2) mixed (28.7%); (3) cardio-metabolic (19.3%); and (4) psychotropic (16.4%). The binomial regression logistic model showed that profiles 2 and 3 (and 4 for AD), with a higher drug prescription conditioned probability against classic risk factors, were protective than profile 1 (OR = 0.421, p = 0.004; OR = 0.278, p = 0.000; OR = 0.457, p = 0.040, respectively), despite polypharmacy being significant in profiles 2 and 3 (mean > 7 drugs) vs. profile 1 (1.4 ± 1.6) (p = 0.000). Patients in the latter group were not significantly older, although being aged 65-79 years old quadrupled (OR = 4.217, p = 000) and being >79 tripled (OR = 2.945, p = 0.010) the conversion risk compared to patients <65 years old. According to the proposed analytical model, profiling the heterogeneous association of risk factors, which were taken prior to diagnosis, could be explored as an indicator of prior care and a predictor of conversion to dementia.

High prevalence of frailty in patients with lower urinary tract symptoms

AIM

Older adults are more likely to be frail and have a high prevalence of urological diseases such as lower urinary tract symptoms (LUTS). The purpose of this study was to clarify the prevalence and characteristics of comorbid frailty in older patients with urological diseases.

METHODS

We retrospectively reviewed the medical records of 970 patient who visited the Department of Urology, Juntendo University Hospital between October 2015 and October 2016. Patients were selected who were 65 years of age or older and were being evaluated by the Kihon Checklist (KCL) to assess frailty. We examined the prevalence of comorbid frailty in urological diseases, identified factors associated with comorbid frailty in urological diseases, and examined KCL scores in urological diseases with a high prevalence of frailty.

RESULTS

A total of 405 participants were included. Of these, 21.7% were frail, 20.5% were pre-frail, and 57.8% were robust. LUTS, overactive bladder, and neurogenic bladder showed a statistically significant relationship with comorbid frailty, with high frailty prevalence rates of 44/140 (31.4%), 19/36 (52.8%), and 4/6 (66.7%), respectively. Factors related to the comorbid frailty according to multivariate analysis were female sex (P = 0.001), older age (P < 0.001), and LUTS (P < 0.033). Of the KCL subscale scores, instrumental activities of daily living (P = 0.008), physical function (P < 0.001), oral function (P = 0.008), housebound (P = 0.009), and depression (P = 0.034) were higher in LUTS patients than in non-LUTS patients.

CONCLUSIONS

Among patients with urological diseases, those with LUTS were found to have a high prevalence of frailty. Geriatr Gerontol Int 2023; 23: 609-615.